Provider Demographics
NPI:1689656894
Name:HELMUS, JOANN LICITRA (OD)
Entity Type:Individual
Prefix:DR
First Name:JOANN
Middle Name:LICITRA
Last Name:HELMUS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:353 2ND ST
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-4607
Mailing Address - Country:US
Mailing Address - Phone:530-758-2122
Mailing Address - Fax:530-758-1448
Practice Address - Street 1:353 2ND ST
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-4607
Practice Address - Country:US
Practice Address - Phone:530-758-2122
Practice Address - Fax:530-758-1448
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 008488 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4046062OtherBC/BS OF TENNESSEE
CAZZZ58352ZOtherBS/BC OF CA
CASD0072150Medicaid
CACH004ZMedicare PIN
CAZZZ58352ZOtherBS/BC OF CA
CASD0072150Medicaid